Better Care Across the System for Children and Young People with Asthma

Better care across the system for children and young people with asthma

Introduction

Asthma is a long-term inflammatory condition that affects the airways,causing wheezing, coughing, chest tightness and breathlessness.Asthma cannot be cured, but with appropriate simple approaches to management quality of life can be improved.
Asthma is the most common long term medical condition among children in the UK, affecting roughly 10% of all children.More than 240,000 children and young people in London have asthma which equates to around three children in every classroom.

Asthma can have a major impact on a child’s life; they may have to take time off school which can affect their learning while time in hospital can be distressing. It may also reduce their ability to exercise. Asthma can also be deadly. Approximately, 25 to 30 children and young people die from asthma each year in the UK, including approximately 12 children and young people in London. It is hoped that 100% of deaths will be preventedby using elements of the Healthy London Partnership asthma toolkit.

A high number of children are admitted to hospital as a result of problems with their asthma in London. On average there is an admission every 20 minutes (over 4,000 emergency hospital admissions per year). 75% of these admissions are avoidable1.

Asthma costs the NHS more than £1billion in medicines, GP visits and hospital admissions every year[1].

London and the UK has a higher rate of child asthma deaths when compared to other European countries. 90% of these deaths are preventablein children who were otherwise healthy and should have gone on to lead a full and productive life.1

The realisation that professional lack of knowledge of, or the inability to follow national guidance is the major modifiable factor in these deaths, means we do not have to wait for new medicines or a cure, but educate our workforce to achieve improved outcomes.

This document outlines the policy context, issues in London, factors for consideration and the desired outcomes.

The vision for improving asthma care, by reducing deaths and avoiding admissions, in the capital is based on:

Forming a critical mass of educated asthma professionals dedicated to continuous improvements in the care of children and young people with asthma.
Working through a networked and integrated care approach to children and young people’s asthma services, producing a single, seamless and overarching governance service that is proactive, accessible and co-ordinated.
With a clear named lead in all organisations responsible and accountable for asthma and the delivery of London’s ambitions for asthma, which are outlined in the London asthma standards for children and young people.

Overarching goals

Have a named responsible individual is identified for liaison and decision making within each organisation,This was a key component of Finland’s strategy to improve asthma across the whole country.[2]
Strengthened role of the child, family and asthma nurse
Greater role of prevention and public awareness
Access to quality care through education and use of agreed guidelines and checklists
Greater role for self-management and the use of asthma action plans
Greater integration of care
Achievement of Healthy London Partnership Children and Young People’s asthma ambitions and standards.

Background

The UK has one of the highest prevalence of asthma in the world[3]. Prevalence in London is lower than the rest of England[4]. The expected prevalence in London is 9%[5], but it is currently only 4.7%, ranging from 3.5% to 5.7% probably due to under diagnosis4.

Levels of mortality and morbidity in children and young people remain high.[6] The first National Review of Asthma Deaths (NRAD) (2014) found 14% of deaths were in the under 19 age group and care fell well below that expected in half of these.

A useful tool exists where you can compare your local CCG with the rest of London or individual CCGs. It is available on the Inhale Interactive Health Atlas of Lung conditions in England and includes data about prevention, diagnosis, outcome and spend.

Childhood asthma is one of three long term conditions supported by NHS England (NHSE), along with childhood epilepsy and diabetes.

London has a diverse, mobile population of over eight million people and approximately a quarter of this population (2,163,500) are children or young people aged 0-20.[7] Asthma is the most common long term medical condition in children, estimated to affect more than 240,000 children in London[8].

Asthma accounts for one in five consultations with a GP.[9]It is most common in children aged between five and 15.NHSEngland has recognised childhood asthma as a national long term problem, leading to the development of National Institute of Health and Care Excellence (NICE) quality standards[10], more than 16 documents of guidance including London asthma standards for children and young people[11][12][13][14] and the creation of a National Paediatric Asthma Collaborative.

National clinical guidance is available, and has been available for over 20 years,6 but implementation is variable which is results in variable local outcomes (Atlas of Variation).

In 2013, Asthma UK foundthat the majority of asthma patients were 'not getting adequate care,' with 80% of asthma sufferers receiving inadequate care.Only 14% of people in London were found to be receiving care that met the national standards. Comparatively 35% of people living in Northern Ireland received the right standard of care.

In 2015, the Secretary of State promised every person with asthma would have an asthma action plan, this commitment has not been met. People who use a written action plan are four times less likely to have to go to hospital for their asthma. London has very low numbers of children with an asthma management plan, 28% compared to 34% nationally. London also compares unfavourably in terms of the number of children and young people who have an annual asthma review, 68% compared to 76%nationally [15].

London continues to have significant variation in diagnosis, treatment, care and outcomes with high admission rates,[16]high morbidity and unnecessary mortality; and rising numbers of respiratory deaths particularly in the 1-4 year age group[17] . It is estimated that 75% of hospital admissions for asthma and 90% of deaths related to the condition are preventable with optimal care.1. [18]

Policy Context

The case for change has been informed by the following policies:

The Government’s Mandate to NHS England,[19]The NHS Outcomes Framework[20] (Department of Health, 2015) and the Outcomes Strategy for COPD and Asthma[21]set out clear priorities to improve the care and treatment for children and young people with respiratory disease, in particular asthma and lower respiratory tract infections.

The National Institute for Health Care and Excellence (NICE) quality standards define best practice, high-quality care for asthma. They provide quality statements, measures and descriptors for the public, health and social care professionals, commissioners and service providers to improve outcomes in care for patients aged 12 months and above.

In 2014 the British Thoracic Society and Scottish Intercollegiate Guidelines Network made recommendations based on current evidence for best practice in the management of asthma adults and adolescents over 12 years old, children 5–12 years, and children under 5 years.The evidence showed that following discharge from hospital or emergency departments, more than 15% of children and young people are readmitted or re-attend within two weeks with many delaying seeking help, and often under-treated and/or under-monitoredError! Bookmark not defined..
The National Review of Asthma Deaths (NRAD) publishedareview in 2014 and identified poor management, patients not receiving key elements of routine care, lack of appropriate onward referral and widespread prescribing errors[22]. They outlined 17 key findings and made 19 recommendations for change in the care of people with asthma. However, they only reported on 190 out of potentially 900 deaths from asthma as there was no easy access reporting structure. The review therefore gives insight into causes but not into the true number of deaths.

The review made a number of recommendations which the former London Children’s Strategic Clinical Network Asthma Group and the London Respiratory Network have responded to and can be found here:

London Respiratory Network and Children’s Strategic Clinical Network Asthma Group’s response to ‘Why asthma still kills: The national review of asthma deaths (NRAD)’ Promoting best asthma care throughout London:

Appropriate implementation of national guidance and the London standardswill help prevent children and young people dying from asthma.

Implementation of a plan similar in style to that in Finland would help.2

This 10 year programme resulted in:

Diagnosis

Medication prescribed

Saw a:

Hospitalisation

0 Deaths

If this is achievable for a country it is achievable for London.

London Issues

The Healthy London Partnership Children and Young People’s transformation programme has identified asthma as one of its key priority areas of work.

We have identified London as having:

Higher than the rest of the country and rising numbers of respiratory deaths particularly in the one to four year age group[23]
High variation in diagnosis, treatment and care
High admission rates[24]
Low numbers of children with an asthma plan (28%) compared to 34% nationally or having had an asthma review (68%)compared to 76% nationally [25]although our recent London Pharmacy Public Health [MVR1]campaign audit showed an increase in this figure.

We have also identified asthma as a priority through a review of serious incidents[26] across London involving children and data from the child death review panels.

Variation in diagnosis, treatment and care

Variation in children’s healthcare is well known. Socioeconomic status, ethnicity, health need and choice are all factors in why provision may differ. However, unwarranted variation due to differences in care quality, efficiency and equity need to be considered and reduced. There is variation in admission rates from borough to borough but also from year to year (see Table 2 below).

High emergency admission rates

There were 26,469 emergency admissions in the UK for children with asthma in 2014/15 which has slowly risen from 23,287 in 2011/12.[27] 4,255 of these were in London. 90% of asthma admissions for children were emergency admissions. The average hospital admission rates for asthma (in under 19 year olds) for London in 2014/15 was 205 per 100,00027

London Area / Emergency Admissions / Emergency Admission rate per 100,000 population
SPG / Area Name / 2012/13 / 2013/14 / 2014/15 / 2012/13 / 2013/14 / 2014/15
North Central London / NHS Barnet CCG / 111 / 99 / 125 / 124 / 109 / 135
NHS Camden CCG / 79 / 65 / 79 / 184 / 146 / 170
NHS Enfield CCG / 116 / 125 / 189 / 138 / 147 / 219
NHS Haringey CCG / 122 / 111 / 107 / 200 / 180 / 171
NHS Islington CCG / 94 / 95 / 122 / 239 / 235 / 296
North East London (1) / NHS City and Hackney CCG / 184 / 152 / 95 / 301 / 243 / 149
NHS Newham CCG / 239 / 193 / 226 / 285 / 226 / 261
NHS Tower Hamlets CCG / 94 / 108 / 127 / 156 / 171 / 193
NHS Waltham Forest CCG / 210 / 241 / 172 / 319 / 360 / 255
North East London (2) / NHS Barking and Dagenham CCG / 125 / 100 / 142 / 214 / 166 / 230
NHS Havering CCG / 57 / 70 / 78 / 105 / 127 / 138
NHS Redbridge CCG / 171 / 161 / 194 / 226 / 210 / 249
North West London / NHS Brent CCG / 166 / 207 / 171 / 220 / 272 / 220
NHS Ealing CCG / 235 / 213 / 177 / 287 / 256 / 210
NHS Hammersmith and Fulham CCG / 54 / 39 / 40 / 157 / 112 / 113
NHS Harrow CCG / 160 / 153 / 151 / 274 / 260 / 254
NHS Hillingdon CCG / 104 / 106 / 147 / 149 / 149 / 202
NHS Hounslow CCG / 98 / 99 / 99 / 157 / 156 / 154
NHS Kensington and Chelsea CCG / 38 / 44 / 35 / 135 / 155 / 121
NHS Westminster CCG / 55 / 49 / 51 / 139 / 120 / 120
South East London / NHS Bexley CCG / 97 / 96 / 104 / 168 / 165 / 177
NHS Bromley CCG / 94 / 104 / 100 / 128 / 140 / 133
NHS Greenwich CCG / 146 / 149 / 195 / 222 / 223 / 287
NHS Lambeth CCG / 180 / 199 / 191 / 281 / 307 / 293
NHS Lewisham CCG / 263 / 163 / 184 / 389 / 237 / 263
NHS Southwark CCG / 158 / 166 / 180 / 250 / 259 / 278
South West London / NHS Croydon CCG / 327 / 343 / 331 / 342 / 355 / 341
NHS Kingston upon Thames CCG / 64 / 38 / 81 / 174 / 101 / 210
NHS Merton CCG / 88 / 116 / 116 / 189 / 246 / 244
NHS Richmond upon Thames CCG / 41 / 36 / 57 / 94 / 81 / 125
NHS Sutton CCG / 67 / 90 / 77 / 144 / 191 / 161
NHS Wandsworth CCG / 96 / 125 / 112 / 162 / 206 / 181
Total Emergency Admissions / 4,133 / 4,055 / 4,255

The total emergency admissions have risen slightly in the last three years from 4,133 to 4,255 with the average emergency admissions rate per 100,000 remaining around 205 (range 113 - 341).Emergency admissions for asthma show a threefold variation across boroughs in Londonwith Croydon at the highest and Hammersmith and Fulham having the lowest admission rate at 113 per 100,000 population(see Table 2).

It is hoped that this toolkit will enable areas whose rates are rising to be able to learn from areas such as City and Hackney who have halved their rate in the last three years and Lewisham and Waltham Forest where rates have also dropped.

Interestingly, Croydon and Islington who both have a strong focus on asthma and feature in some of our case studies rates have remained quite high but this could be due to greater education and more emphasis leading to more appropriate identification and management.

Emergency hospital admissions, bed days and lengths of stay for asthma, under 19s, London by CCG, 2014/15
2014/15
CCG_Responsibility / No of admissions / No of discharges / Admissions (rate per 100,000 population) / Bed days / Bed days (rate per 100,000 population) / Average length of stay (LOS) / Population1
NHS Barking & Dagenham / 139 / 141 / 223.0 / 193 / 309.7 / 1.37 / 62,327
NHS Barnet / 128 / 130 / 137.7 / 113 / 121.5 / 0.87 / 92,969
NHS Bexley / 105 / 109 / 190.5 / 98 / 177.8 / 0.90 / 55,107
NHS Brent / 184 / 183 / 224.6 / 163 / 199.0 / 0.89 / 81,916
NHS Bromley / 96 / 96 / 126.9 / 133 / 175.8 / 1.39 / 75,664
NHS Camden / 82 / 86 / 179.6 / 112 / 245.3 / 1.30 / 45,660
NHS City and Hackney / 106 / 110 / 155.6 / 100 / 146.8 / 0.91 / 68,102
NHS Croydon / 333 / 354 / 349.9 / 350 / 367.8 / 0.99 / 95,173
NHS Ealing / 180 / 183 / 187.7 / 177 / 184.6 / 0.97 / 95,898
NHS Enfield / 170 / 174 / 206.1 / 249 / 301.9 / 1.43 / 82,491
NHS Hounslow / 101 / 100 / 147.0 / 141 / 205.2 / 1.41 / 68,724
NHS Greenwich / 206 / 223 / 296.8 / 274 / 394.8 / 1.23 / 69,408
NHS Hammersmith and Fulham / 43 / 43 / 112.8 / 69 / 181.1 / 1.60 / 38,109
NHS Haringey / 119 / 125 / 182.7 / 167 / 256.4 / 1.34 / 65,124
NHS Harrow / 141 / 141 / 239.5 / 86 / 146.1 / 0.61 / 58,871
NHS Havering / 90 / 91 / 155.2 / 108 / 186.3 / 1.19 / 57,985
NHS Hillingdon / 134 / 135 / 187.3 / 150 / 209.7 / 1.11 / 71,535
NHS Islington / 119 / 131 / 286.7 / 147 / 354.2 / 1.12 / 41,504
NHS Kingston / 95 / 103 / 214.2 / 155 / 349.4 / 1.50 / 44,360
NHS Lambeth / 220 / 227 / 306.0 / 370 / 514.6 / 1.63 / 71,902
NHS Lewisham / 184 / 186 / 257.2 / 241 / 336.8 / 1.30 / 71,551
NHS Newham / 234 / 243 / 248.0 / 268 / 284.0 / 1.10 / 94,373
NHS Redbridge / 174 / 175 / 228.8 / 197 / 259.0 / 1.13 / 76,055
NHS Richmond / 52 / 54 / 110.5 / 85 / 180.7 / 1.57 / 47,049
NHS Southwark / 179 / 191 / 275.1 / 251 / 385.8 / 1.31 / 65,062
NHS Merton / 111 / 124 / 227.3 / 161 / 329.7 / 1.30 / 48,830
NHS Sutton / 74 / 81 / 166.5 / 109 / 245.3 / 1.35 / 44,435
NHS Tower Hamlets / 132 / 136 / 199.8 / 192 / 290.7 / 1.41 / 66,056
NHS Waltham Forest / 183 / 185 / 255.4 / 169 / 235.9 / 0.91 / 71,641
NHS Wandsworth / 123 / 128 / 169.6 / 215 / 296.5 / 1.68 / 72,517
NHS West London (Kensington and Chelsea, Queen’s Park and Paddington) / 55 / 54 / 128.9 / 78 / 182.8 / 1.44 / 42,660
NHS Central London (Westminster) / 39 / 39 / 117.6 / 45 / 135.7 / 1.15 / 33,152
London / 4,331 / 4,481 / 208.6 / 5,366 / 258.5 / 1.20 / 2,076,210
1Number of Patients Registered at a GP Practice as at January 2015 (<19 year olds)
Source / Hospital Episode Statistics (HES), Health and Social Care Information Centre
Small numbers / To protect patient confidentiality, figures between 1 and 5 have been replaced with “*” (an asterisk). Where it was still possible to identify figures from the total, additional figures have been replaced with "*". Where the symbol "-" (dash) appears this represents the absence of data.
Please note that HES disclosure control rules only apply to 'known' values, e.g. small numbers where the age is unknown do not need to be replaced with "*".
Finished Admission Episodes (FAEs) / A finished admission episode (FAE) is the first period of admitted patient care under one consultant within one healthcare provider. FAEs are counted against the year or month in which the admission episode finishes. Admissions do not represent the number of patients, as a person may have more than one admission within the period.
Inclusions / Exclusions: / Description / HES code
Finished admission episodes / EPIORDER = 1 and EPISTAT = '3'
Regular day patients are excluded from analysis / CLASSPAT = 1, 2, 5
London responsible CCGs only / CCG_responsibility in ('07L','07M','07N','07P','07Q','07R','09A','07T','07V','07W','07X','08A','08C','08D','08E','08F','08G','07Y','08H','08J','08K','08L','08R','08M','08N','08P','08Q','08T','08V','08W','08X','08Y')
Primary dignosis is asthma / Diag_01 in ('J45','J46')
Children and young people under 19s only / Startage < 19
Emergency admissions / Admimeth in ('21','22','23','24','28','2A','2B','2C','2D')
Copyright / Copyright © 2016, Health and Social Care Information Centre. All Rights Reserved.
Analysis by PHE Knowledge and Intelligence Service (London), April 2016

Figure 4 London emergency admissions for asthma

Data are for 2014/15, and relate to emergency admissions for asthma; ICD10: J45 or J46

Financial impact

Asthma has a significant impact on NHS spending; it was estimated to cost the NHS £1billion in 2004.[28] In comparison the cost of COPD and asthma in Europe is over £200 billion Euros.[29] The cost of treating a child with asthma is higher than the cost per adult.[30] Based on findings from a study by Hoskins et al (2000),[31] a patient who experiences an acute asthma attack is likely to cost 3.5 times that of a patient who does not.[32] This could come down by a reduction in the length of stay or better still preventing the exacerbation in the first place.[33]

The costs of emergency admissions for asthma for each CCG in London are listed in Table 5 below.

The current amount spent by CCGs ranges from over £232,362 in Croydon compared with £24,570 in Kensington and Chelsea.

Table 5Number and cost of emergency admissions for asthma for children aged 0-18 - 2013/14 and 2014/15

aSource: Health and Social Care Information Centre (February 2016, based on number of patients registered at a GP Practice

b2014/15 Hospital Episode Statistics

cBased on PBR rate of £702 per emergency admission

The current cost of emergency admissions per 100,000 population based on £702 PBR rate equates to London spending £4,600,200 per year.

If 60% of child emergency admissions for asthma were prevented, this would mean asthma admissions would cost London£1,840,082 amounting to around£2,760,124million in savings across London.

If CCGs were able to achieve the 75% reduction this would be even greater at around £3,450,154 savings.

If adult asthma was included in the plans there would be even greater returns.

In addition, the combined prescribing costs for bronchodilators and corticosteroids alone, in children and adults,is £1,031,720,912 in England and £105,702,558.87 in London. It is possible there would be a slight rise in drug costs as patients were prescribed more appropriately. This is what was found in the Finnish study2.Between 30% and 50% of prescribed medicines for long-term conditions are not taken as recommended. We need to make sure our children are receiving support to take their medicines so they receive the health benefits and the NHS gets value for money from those drugs dispensed.

These costs include diagnosis, acute and primary care, and medications, but there are significant indirect costs, beyond healthcare, to the wider economy:

A child with poorly controlled asthma is three times more likely to take time off school than a child whose condition is well controlled.
Poor school attendance is likely to have a detrimental effect on emotional wellbeing and educational attainment.
A carer is four times more likely to take time off work, with a further effect on their own productivity.

Summary findings

Many children have poor control of their asthma. Improved adherence with therapy would help reduce exacerbations and hospital admissions. Hospital admission for children and young people with asthma is a proxy for failure of asthma managementand acts as an indicator of poor symptom management.